The use of pericranial flaps for reconstruction and elevation of the lower eyelid

We present the novel approach of using pericranial flaps to reconstruct posterior lamellar eyelid defects or to achieve lower eyelid elevation. This technique has been employed in patients where standard tarso-conjunctival flaps are not an option and free posterior lamellar grafts cannot be supported due to the lack of viable anterior lamellar flaps.

Pericranial flap, comprising inferiorly based forehead periosteum and the overlying loose areolar tissue, is constructed using a vertical paramedian forehead incision. Flaps are tunnelled subcutaneously to emerge at the proximal aspect of the eyelid defect and extend to the lateral orbital rim. They are secured with absorbable sutures. An overlying full-thickness free skin-graft or flap is used for the anterior lamella.

Eight patients underwent reconstruction or lower lid elevation. All patients achieved the predicted lower eyelid height with good cosmesis. Median follow-up 7.5 months (6-24 months). Indications were lower lid scarring/retraction (4), facial palsy (1), post BCC reconstruction (2), and exposed keratoprosthesis (1). In 2 (of 5) patients who had free skin-grafting, the overlying free skin-graft did not survive but acted as a biological dressing. All such patients still had good outcomes after epithelialisation of the flap. The posterior aspect of the pericranial flaps seems to act as an ideal substrate for conjunctivalisation, with little detrimental effect on the cornea. The robustness of the flap prevents the development of lid laxity over time.

The pericranial flap is a versatile and robust flap that yields good cosmetic and functional outcomes when used in the reconstruction of posterior lamellar eyelid deficits. It is likely that, even when not viable, overlying free skin-grafts act as an excellent biological dressing until epithelialisation occurs.